Orthopedic Coding Alert

Documentation—by both the primary and specialist physician—is the key to get specialty services paid as a consultation.

Medicare’s revision in the Carrier’s Manual (MCM) Transmittal No. 1644 did, however, resolve lingering issues from a previous revision about when a transfer of care occurs.

"HCFA is responding to the confusion in the coding and clinical community, but only to a point. Sometimes they make these things ambiguous on purpose. They don’t want to make it so specific that they back themselves into a corner. This will leave people arguing about the definition of complete care," says Deb Lief, CPC, manager of coding compliance at ProMedCo in Fort Worth, TX. Lief is also president of the North Texas Chapter of the American Academy of Professional Coders.

The transmittal, a revision of section 15506 of the MCM, states that a consult may be billed regardless of treatment initiation unless a transfer of care occurs. A transfer of care occurs when the referring physician transfers the responsibility for the patient’s complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance. It was intended to clarify an update issued in July 1998 that made clear a consultant could initiate diagnostic and therapeutic services on the same day but added confusion by stating the visit could not be billed as a consult if partial or total care of the patient had been transferred.

The two transmittals, which involve Sections A and B of 15506, should make it more evident that even when specialists initiate treatment, they are still performing a consultation. In fact, the two more closely align Medicare’s definition of a consultation with that of CPT 1999, which states that a physician consultant may initiate diagnostic and/or therapeutic services.

However, they seem to conflict with Section G of 15506, which has not been updated. A guideline for consults during post-operative care, Section G says that If the surgeon asks a physician who had not seen the patient for a preoperative consultation to take responsibility for the management of an aspect of the patient’s condition during the postoperative period, the physician may not bill a consultation because the surgeon is not asking the physician’s opinion or advice for the surgeon’s use in treating the patient. The physician’s services would constitute concurrent care and should be billed using the appropriate level visit codes.

These discrepancies have caused disagreement in the professional coding community and may leave practices open to denials, depending on carriers’ reading of the updates and Section G, and their definition of "complete care."

Documentation is Key

Requests for consultation often start over the telephone. A family practitioner, for example, may call an orthopedist and ask him to evaluate a patient complaining of pain in his leg following exercise. That initial conversation should clarify the family practitioner’s expectations and the orthopedist’s involvement, according to Blair Filler, MD, FACS, director of medical education at the Los Angeles Orthopedic Hospital in Los Angeles, CA. "The key is that before the (consulting) physician sees the patient, he has not agreed to take over the care for the patient," he advises.

It is also important that the consulting physician is not merely following the instructions of the requesting physician. For example, if a family practitioner sends a patient to an orthopedist and specifically requests a bone density scan, that would not be considered a consult because the orthopedist is following the family practitioner’s instructions.

The physician-to-physician request for consultation should be followed in writing by both parties.

The requesting physician should send a brief letter to the specialist documenting the request. He should avoid using the words "referral" or "transfer," according to Lief. Both physicians may well understand that the requesting physician is only asking the specialist to diagnose and treat a specific aspect of his patient’s condition, but the Medicare carrier may see it as a clear indication that he was asking the specialist to assume complete care responsibilities, she explains.

Once the consulting physician sees the patient, he should send a written communication explaining his diagnosis and treatment to the requesting physician.

This request-render-report cycle is described in Transmittal 1644’s guidelines for consultation:

1. A consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source (unless it is a patient-generated confirmatory consultation).
2. A request for a consultation from an appropriate source and the need for consultation must be documented in the patient’s medical record.
3. After the consultation is provided, the consultant prepares a written report of his/her findings which is provided to the referring physician.

Clear documentation will demonstrate the appropriate use of consultative codes and help refute any carrier denials.

Although requests for consultation often involve primary-care physicians and specialists, the guidelines for consultative services also apply to intra-practice requests, according to Filler. For example, a member of the practice who specializes in sports medicine may ask for a consultation from one of his partners on a patient with low-back pain.